This needs assessment identifies the main water and sanitation challenges in Mekelle and the investment levels required to meet Target 10 of United Nations Millenium Development Goals (MDG) 7. There is a need to improve water supply and sanitation, sewage treatment and hygiene education in Mekelle. The findings of this needs assessment indicate that in order to meet MDG targets related to water and sanitation, spending per capita needs to increase from about $10 in 2010 to $12 in 2015. MCI believes that this modest increase made over five years can dramatically improve Mekelle citizens’ access to safe water and sanitation as well as the public health citywide and is well worth the incremental additional investment.